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Pages with reference to book, From 61 To 62

Pushpa S. Sachdewani ( Department of Obstetrics and Gynaecology, Liaquat Medical College, Jamshoro, Sindh. )


Two unusual cases of advanced twin pregnancy are described in both cases one foetus was in the uterus and other in the abdominal cavity. Combined intrauterine and extrauterine pregnancy was first reported in 1708 AD. It has been mentioned in recent literature that an intra-uterine pregnancy rules out an ectopic pregnancy, but this is no longer considered true. Because heterotopic pregnancy now a days is not thought to be a medical curiosity, it should always be considered in differential diagnosis of abdominal pain pregnancy1. The incidence of heterotopic pregnancy is higher in certain high risk groups. However no risk factor was identified in both the cases mentioned here.



Parenteral antibiotics were commenced to combat infection and intravenous fluids administered to correct dehydration. Laparotomy was performed on November 22, 1982. A small amount of foul smelling dirty coloured fluid was found filling the peritoneal cavity. A thick walled sac was attached to the right side of uterus and right ovary and fallopian tube. The sac was incised and a malformed

maccrated foetus of about 24 weeks gestation was delivered. The placenta was firmly adherent to the ovary and tube and hence its removal necessitated right salpingo-oophorectomy. Total amount of blood loss during operation was about 300 ml. Patient remained pyrexial during postoperative period but subsequently settled on broad spectrum antibiotics.


A 30 year old woman para 5+2 presented to the department of obstetrics and gynaecology, People’s Medical College Hospital, Nawabshah on March 15, 1990 complaining of abdominal pain and distension following home delivery 10 days ago. At the time of admission, on physical examination, she appeared to be in pain, was mildly anaemic and dehydrated having temperature of 38°C. A poorly defined tender abdominal mass corresponding to 34 weeks of gestation was palpable. Pelvic


the clinical presentation and laboratory data a provisional diagnosis of ovarian tumour with complications was made. Exploratory laparotomy was performed 6 hours later. On opening the

abdomen there was no blood or free fluid in the peritoneal cavity. A thick walled cystic mass was found adherent to the posterolateral aspect of uterus, the left broad ligament and rectovaginal pouch. During dissection the sac ruptured and a full term macerated female foetus weighing 2.0 kg was delivered. The placenta was attached to the posterior aspect of the uterus. Fortunately there was no difficulty in

separation and removal of placenta. Patient had an uneventful postoperative recovery.


Ultrasonography would have been useful in diagnosing both cases but unfortunately could not be carried out which limited our preoperative diagnosis. In case 2, abdominal foetus was fully developed with no congenital anomaly and would’ have ‘been saved if condition was diagnosed earlier when the foetus was still alive. In case 2 maternal morbidity would have been reduced by early surgical

intervention. Abdominal pregnancy is a rare form of pregnancy; incidence varies from 1:6,000 to 1:10,000 term births2. Pregnancies occurring simultaneously in different body sites (heterotopic pregnancies) is still a rarer event occurring in 1:30,000 term births3. The current epidemic of PID (pelvic inflammatory disease) and recent advances in gynaecological techniques of assisted

reproduction such as in vitro fertilization and wider use of ovulatory induction drugs have increased the incidence of combined intra and extra uterine pregnancies4,6. The abdominal pregnancy produces considerable morbidity and mortality both for foetus as well as mother, the maternal mortality rate may reach up to 18%. The major causes of maternal death are sepsis, haemorrhage, bowel complications and difficulty in separation of placenta. The factors which decrease maternal mortality may depend upon either earlier diagnosis7-9 or prompt surgical intervention10,11. Early diagnosis depends on high index of suspicion of heterotopic pregnancy7 and utilization of technical aids such as transvaginal ultrasonography which is the most sensitive index in the diagnosis of early ectopic pregnancy8,9.


I would like to express thanks to Professor Aftab Munir for the excellent guidance and assistance. Grateful acknowledgement is also made to Dr. S.H. Piriyani for helping in the preparation of this manuscript.


1. Bright, D.A. and Gaupp, F.B., Heterotopic pregnancy. J.Am.Board. Pam, Pract., 1990;3:125-28. 2. Geerinckx, ICR., Baekelandt, M., Dauwe, D. and Pandelaere, 1. An advanced abdominal twin gestation after primary infertility and after tubal pregnancy Eur.J.Obstet.Gynecol.Reprod.Biol., 1987;26:283-8.

3. Molloy. D., Deambroais, W., Keeping, D., Hynes, J., Harrison, K. and Henneasey, 3. Multiple sited (heterotopic) pregnancy after in-vitro fertilization and gamete intrafallopian transfer. Pertil.Sterit, 1990;53:1068-71.

4. Kouyoumdjian, A. and Kirkpatrickl 3. COexistence of an intrauterine pregnancy with both an ectopic pregnancy and salpingitia in the right fallopian tube. A case report. J.Reprod.Med., 1990;35:824-6. 5. Dimitry, ES., Subak, Sharpe, R., Mills, M., Margara, P.. and Winston, P. Nine cases of heterotopic pregnandes in 4years of in-vitro fertilization. Fertil.Steril., 1990;53:107-10.


fertilization and ovulatory drugs. Ann.Emerg.Med., 1988;17:846-49.

7. Back, P., Silverman, M., Ochninger, S., Muasher, S.J., Acosta, A.A. and Rosenwaks, Z. Survival of cornual pregnancy in a heterotopic gestation after in-vitro fertilization and embryo transfer.

Pertil.Steril., 1990;53:732-34.

8. Kivikosky. AL, Martin, CM., Smeltzar, 3.5. Transabdominal and transvaginal ultrasonography in the diagnosis of ectopic pregnancy: a comparative study. Am.J.Obstet.Gynecol., 1990;163:123-28.

9. Rizk, B., Tan, S.L., Morcos, S., Riddle, A., Brinsden, P., Mason, B.A and Edwards, R.G., Heteropie pregnancies after in-vitro fertilization and embryo transfer. Am.J.Obstet.Gynecol., 1991;164:161-4. 10. Oaguthorpe, N.C. and Keating, CE. Ectopic pregnancy. Surgical intervention and perioperative nursingcare. AORN.J., 1988;48:254-57, 259-63, 265-67 Passim.


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